Management of High Lactate Levels
Treat elevated lactate (>2 mmol/L) as a medical emergency requiring immediate aggressive fluid resuscitation with at least 30 mL/kg IV crystalloid within 3 hours, followed by lactate-guided resuscitation targeting normalization while addressing the underlying cause. 1, 2
Immediate Resuscitation Protocol
Initial Fluid Resuscitation
- Administer 30 mL/kg of IV crystalloid fluid within the first 3 hours as the cornerstone of initial management for sepsis-induced hypoperfusion with elevated lactate 1, 2
- This fixed volume enables rapid resuscitation while obtaining more specific hemodynamic information 1
- Many patients will require additional fluid beyond this initial bolus based on reassessment 1
Hemodynamic Targets
- Target a mean arterial pressure (MAP) of 65 mm Hg in patients requiring vasopressors, as this provides optimal outcomes without increased arrhythmia risk seen with higher MAP targets 1, 2
- Use dynamic variables (e.g., pulse pressure variation, stroke volume variation) over static variables (e.g., CVP) to predict fluid responsiveness when available 1
Lactate-Guided Resuscitation
- Guide ongoing resuscitation to normalize lactate levels as a marker of tissue hypoperfusion, which has demonstrated mortality reduction (RR 0.67; 95% CI 0.53-0.84) 1, 2
- Measure serial lactate levels to monitor treatment response and prognosis 2, 3
- Lactate clearance during resuscitation is associated with improved outcomes across multiple trials 1
Diagnostic Considerations
Identify the Underlying Cause
- Sepsis and septic shock are the most common causes requiring urgent antimicrobial therapy after obtaining cultures 1, 2, 4
- Mesenteric ischemia should be considered when lactic acidosis presents with abdominal pain; obtain early CT angiography 2
- Cardiac failure and low-flow states can cause tissue hypoxia and lactate elevation 2, 4
- Consider non-hypoperfusion causes including medications, seizures, thiamine deficiency, malignancy, and liver failure 4
Assess for Tissue Hypoxia vs. Impaired Oxygen Utilization
- Check ScvO2 if available: only 35% of septic patients have ScvO2 <70%, suggesting impaired oxygen utilization rather than delivery is often the primary mechanism 5
- Evaluate renal function (creatinine) as concomitant acidemia typically only occurs with renal dysfunction 5
- Calculate "alactic base excess" (lactate + standard base excess): negative values indicate acidemia from renal dysfunction, positive values suggest relative alkalosis despite hyperlactatemia 5
Critical Pitfalls to Avoid
Fluid Overload Risk
- Do not blindly pursue lactate normalization with excessive fluids, as hyperlactatemia in sepsis more frequently results from impaired oxygen utilization rather than inadequate oxygen delivery 5, 6
- Reassess hemodynamic status frequently using clinical examination and available monitoring before administering additional fluids 1
- One trial showed potential harm with lactate-guided therapy compared to capillary refill time-guided resuscitation 6
Bicarbonate Administration
- Avoid routine bicarbonate administration for lactic acidosis unless pH is severely depressed and causing hemodynamic instability 7
- If bicarbonate is used, administer 2-5 mEq/kg over 4-8 hours with careful monitoring of blood gases and plasma osmolarity 7
- Rapid correction can cause unrecognized alkalosis due to delayed ventilatory readjustment 7
Diagnostic Specificity
- Recognize that lactate elevation is not specific to infection and may trigger unnecessary broad-spectrum antibiotics 6
- Hyperlactatemia does not always reflect fluid-responsive hypoperfusion 6
Ongoing Management
Monitoring Strategy
- Perform frequent reassessment including heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and urine output 1
- Serial lactate measurements have strong prognostic value and should guide therapy adjustments 1, 2, 3
- Monitor for organ dysfunction as lactate levels correlate with severity scores and 90-day mortality 5